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ECG Interpretation Cheat Sheet
ECG Interpretation Cheat Sheet
An ECG (or EKG) – which stands for electrocardiogram – looks at an electrical tracing of the
cardiac activity within your heart. Changes can indicate structural, mechanical, or electrical issues.
The electrical tracing is referred to as a rhythm strip. Depending on the number of electrodes, this
gives various different leads or views of the heart.
The most common ECG is a 12-lead ECG, which utilizes 10 electrodes to get 12 different views of
the heart. However, continuous telemetry monitoring usually utilizes 3-5 electrodes, viewing only a
few important leads, with a primary lead (usually Lead II) being continuously monitored.
Interpreting a 12-lead ECG is advanced – primarily falling on the responsibility of the physician or
advanced practice provider (APP). However, interpreting rhythm strips (in a single lead) is super
important for every inpatient nurse to know – especially those working in the ED, ICU,
Telemetry, or Cardiac units.
Remember the rhythm tracing indicates electrical impulses through the heart cells. Just
because the electrical impulse is there does not mean the heart will have the mechanical
response (i.e. contraction). This is the case during PEA.
The QT interval is the length of time it takes the electrical impulse to go from the beginning
of the ventricles – until the ventricles completely repolarize and are ready for another
contraction. This should be between 350-450 ms. If this is elongated – this presents an
increased risk of various arrhythmias such as Torsades or Vfib, especially if > 500 ms.
However, if the heart rate is abnormally slow (bradycardia) or fast (tachycardia), this will not be
accurately reflected. Due to this, the QT-c (QT-corrected) is usually used which corrects for
the heart rate.
ST depression is defined as greater than 0.5mm (1/2 small box) below the isoelectric line. This
usually indicates cardiac ischemia – meaning there is a lack of perfusion to some area of the
heart. It can also indicate digoxin toxicity or electrolyte abnormalities. ST depression can
either be upsloping, down-sloping, or horizontal – with down-sloping being more specific
for myocardial ischemia.
ST elevation is defined as greater than 1mm (1 small box) in limb leads and 2mm in precordial
leads (V1, V2, V3) above the isoelectric line and indicates myocardial necrosis aka infarction.
This classically occurs during a STEMI (ST-segment elevation myocardial infarction). In order to be
classified as a STEMI – the ST-segment elevation MUST be in 2 contiguous leads.
T waves are typically a smooth “hill”. The T-wave is typically upright in lead II, and variable
in other leads (see below). Any nonspecific T-wave changes could indicate cardiac pathology
as sinister as active ischemia and MI, baseline from previous cardiac injury, or something
completely benign.
ECTOPIC BEATS
Ectopic beats or ectopy are beats originating outside of the SA node (the normal pacemaker of the
heart). Any cells which are irritated from ischemia or damage can produce an electrical impulse
which is conducted by the other heart cells. These ectopic beats may or may not actually
cause contraction of the heart (the impulse may be there but the heart doesn’t respond). This can cause
the feeling of palpitations or skipped beats. Whether or not the
myocardial cells respond, it causes an irregular early beat which
interrupts the normal rhythm. When interpreting rhythms, you
must always interpret the underlying rhythm, and THEN identify
any ectopic beats (i.e. sinus bradycardia with 1 PVC).
Sometimes PVCs will fall into patterns – and there are specific names for these. If every
other beat is a PVC – this is Bigeminy. If every 3rd beat is a PVC – Trigeminy. If every 4th beat is
a PVC – Quadrigeminy. These patterns don’t necessarily mean much other than are known to
occur in a significantly diseased heart, but they are important to note when monitoring the
rhythm over time.
PACs can occur from ischemia and irritability, but can often occur from less dangerous
causes such as caffeine, stress, alcohol, fatigue, poor sleep, and various medications.
Premature Junctional Contractions (PJCs) follow the same principals as above, but they
occur within the AV node between the atria and the ventricles. This means P-waves can be
present but are inverted, but often are absent if hidden within the QRS complex itself.
A SYSTEMATIC APPROACH TO
RHYTHM INTERPRETATION
There are specific steps to take in order to analyze and correctly interpret a rhythm strip. This
becomes especially helpful for those who are new or uncomfortable with analyzing and
interpreting rhythm strips.
1. DETERMINE REGULARITY
Rhythms are split between regular rhythms and irregular rhythms. Generally, regular
rhythms are less ominous but can still be dangerous (i.e. rapid Afib, SVT, aflutter, severe
bradycardia, VTACH). Irregular rhythms usually indicate atrial rhythms, ectopy, or heart
blocks. For sinus rhythms that appear to be a normal rate – you can likely just eyeball
the regularity. However, it can be beneficial to measure the distance between the R
waves of each QRS complex and map out if the R-to-R interval, and make sure it is
generally the same throughout the strip. While doing this, make sure each QRS
complex has a P-wave which precedes it.
2. DETERMINE RATE
There are ways to calculate the rate, but with current technology this will usually be
provided for you. Almost always – you can utilize this calculated rate provided
somewhere on the rhythm strip. However, rarely the machines can count
incorrectly. Rate = ~73 bpm
REGULAR RHYTHMS
NORMAL SINUS RHYTHM (NSR)
NSR is the rhythm that every healthy person should have at rest (aside from fit individuals with SB).
This represents healthy cardiac electrical conduction. Be warned though – if the patient
does NOT have a pulse then this is Pulseless Electrical Activity. This can occur when
the electrical signal is sent but the heart does not respond to this signal.
SINUS BRADYCARDIA
Sinus Bradycardia is just like NSR, but the rate is <60 bpm. This is usually a healthy
variant in certain individuals. Younger fit athletes tend to have resting heartrates 40-60, and
slower while sleeping. Additionally, it is not uncommon for older individuals to have resting
heartrates in the 40s or 50s as well, especially if on Beta-Blockers like Metoprolol. With this
rhythm – it is important to assess whether or not the patient is symptomatic – are they dizzy,
SOB, have chest pain?
JUNCTIONAL RHYTHMS
Junctional rhythms occur when the AV node takes over the job of the SA node – which
is normally the pacemaker of the heart. This occurs in two different scenarios. One, there is
dysfunction of the SA node – this causes a HR of 40-60 bmp termed a “Junctional
escape rhythm”. Or two, for whatever reason the AV node is firing faster than the SA
node – which is termed “Junctional ectopic rhythm”. If the HR exceeds 100 bmp, this is
termed Junctional tachycardia.
PACED RHYTHMS
Paced rhythms occur when the patient has a pacemaker – usually implanted with leads in
the atria only, the right ventricle, both ventricles (biventricular), or both the atria and
the ventricles (dual-chamber). The pacer will spike, causing stimulation of the cardiac
tissue to conduct an electrical impulse. The complexes will look different depending on which
type of pacemaker is present. However, you need to make sure the Pacer spike mode on
your telemetry monitor is set to on – otherwise you may get confused and the pacer spikes
won’t show up on a standard rhythm strip.
SINUS TACHYCARDIA
Sinus tachycardia is a regular rhythm which is just like NSR, except the rate is >100 bpm.
This generally occurs in response to stimulation such as exercise or anxiety, or as a
physiologic response to improve blood flow and oxygenation. This is a very common
rhythm.
SUPRAVENTRICULAR TACHYCARDIA (SVT)
SVT is a type of fast heartrate that originates anywhere above the ventricles, but usually
refers to AVNRT or AVRT. This occurs more frequently in younger and middle-aged
individuals and can be triggered by alcohol, caffeine, or recreational drugs like cocaine.
However, this can occur in older individuals as well, and can be triggered by anything which
stresses the heart (think about Hs and Ts from ACLS).
VTACH Is a serious rhythm that usually indicates an unstable patient. If the patient is
pulseless – this IS cardiac arrest and the patient needs to be coded and defibrillated
ASAP. If there is a pulse – the patient may or may not be reporting symptoms but this is still
a serious situation and the patient can decompensate at any moment. The defibrillation
pads should connect the patient to the defibrillation device, and close communication with
the Provider is imperative.
IRREGULAR RHYTHMS
SINUS ARRHYTHMIA (SA)
Sinus arrhythmia is a (almost always) benign variant of NSR. This means that everything is the
same as NSR except that it is irregular so it will not map out. This commonly occurs with the
respiratory cycle – speeding up during inhalation and slowing for expiration. However, it
can occur in a diseased heart or indicate digitalis toxicity.
ATRIAL FIBRILLATION (AF)
AF is a common cardiac arrhythmia, especially among the elderly. The atria of the heart
quiver or fibrillate instead of beating in an organized fashion. This can cause symptoms
such as fatigue and SOB, and places the patient at increased risk for developing a blood
clot within the heart. However, many elderly patients are asymptomatic and simply live
with this disorder. AF has a tendency to run too fast if the patient is not on a beta-blocker or
calcium-channel blocker. This is termed AF RVR (rapid ventricular response).
Atrial flutter is Afib’s little brother. It is essentially the same rhythm, except the atria are not
quivering quite as fast. This causes visible P-waves which appear in a saw-tooth pattern
– commonly a 2:1 P to QRS ratio. Because this tends to occur in a pattern, it is actually fairly
common for Aflutter to appear regular.
Rate: None
P-waves: Absent
PR-Interval: N/A
QRS: Absent
VFIB is one of the worst-case scenarios and is not a perfusing rhythm. These patients
are in cardiac arrest and will not be responsive or have a pulse. This rhythm is similar to
the concept of AF, except the ventricles are quivering. Within seconds the patient will go
unresponsive due to lack of blood flow to the brain. The patient needs to be coded and
defibrillated ASAP. The sooner they are shocked, the better chance a perfusing rhythm will
be established.
TORSADES DE POINTES
Torsades is actually a type of VTACH. The difference is that it is polymorphic and caused
by QT prolongation. The rhythm literally appears to twist around the isoelectric name –
which is fitting because Torsades De Pointes literally means “twisting of the points” in
French. This is another critical rhythm which can be pulseless and decompensate into
VFIB or asystole
ASYSTOLE
Rate: None
P-waves: None
PR-Interval: None
QRS: None
Asystole is the characteristic “flat-line”. This is a heart that has no electrical conduction
and thus no mechanical beating. These patients are unresponsive and need coded –
however their chances of reestablishing a perfusing rhythm are worse than with pulseless
VTACH or VFIB.
Rate: variable
P-waves: appear normal
PR-Interval: appear unaffected
QRS: appear narrow
PEA mimics bradycardia or sinus rhythm. There are electrical impulses throughout the
heart – but the heart is not responding to that impulse – meaning the heart is not
beating. These patients present the same as Asystole and given time without intervention
will progress to asystole.
HEART BLOCKS
1ST DEGREE AV BLOCK
Rate: Unaffected
P-waves: Unaffected
PR-Interval: >5 small boxes
QRS: Unaffected
A 1st degree atrioventricular block is a common heart block and rather benign. There is
some type of delay or interruption which slows the electrical impulse between the atria
and the ventricles. This is technically not heart block but rather a “prolonged AV conduction”.
Causes include structural abnormalities, various drugs such as beta-blockers or calcium
channel blockers, or previous heart attack.
“If the R is far from P – then you have a 1st degree”
2ND DEGREE TYPE 1 AV BLOCK (WENCKEBACH)
A 2nd degree type 1 AV block or Wenckebach is when the electrical impulse progressively
gets delayed and then completely blocked in a pattern. This means the PR-interval is
normal or prolonged and inconsistent. Occasionally, there will be P-waves where the QRS
is dropped, and the pattern will reset. If symptomatic and hemodynamically unstable –
they should be treated with atropine and temporary pacing – with possible implanted
pacemaker needed.
“Longer longer longer drop – Then you have a Wenckebach”
2ND DEGREE TYPE 2 AV BLOCK (MOBITZ 2)
A 2nd degree Mobitz II AV block is when the electrical impulse occasionally gets blocked to
the ventricles. This means the P-waves are normal or prolonged but consistent. However,
occasionally there will be P-waves where the QRS is dropped. If symptomatic and
hemodynamically unstable – they should be treated with atropine and temporary pacing –
with possible implanted pacemaker needed.
“If some Ps don’t get through – then you have a Mobitz II”
3RD DEGREE AV BLOCK (COMPLETE HEART BLOCK)
Complete heart blocks are ominous, and the patient is almost always symptomatic. This
is when the atria and the ventricles just are not communicating. This means the P-waves will
map out and be regular with each other, and the ventricles will map out and be regular with
each other. However – they will not correlate with each other at all. These patients need
immediate atropine and temporary pacing until a permanent pacemaker can be inserted.
“If Ps and Qs do not agree – then you have a 3rd degree”
Rate: Unaffected
P-waves: Unaffected
PR-Interval: Unaffected
QRS: Widened (>3 small boxes)
Bundle branch blocks occur between the ventricles. This is a fairly common heart block
which slows conduction through the ventricles. This means there is an abnormally
widened and irregular-looking QRS complex which will look different depending on which
lead. There are Right and Left BBBs – however you cannot tell the difference based off of
one rhythm strip. You would need a 12-lead ECG and look at leads V1 and V6.
Other Websites
https://en.ecgpedia.org
https://learningcentral.health.unm.edu/learning/user/onlineaccess/CE/bac_online/index.html
https://litfl.com/ecg-library/
textbooks
Basic Arrhythmias (7th edition) – Gail Walraven
ECGs Made Easy (6th edition) – Barbara Aehlert
Rapid Interpretation of EKGs (6th edition) – Dale Dubin, MD
DISCLAIMER
This PDF is intended for educational purposes only. Please refer to hospital-specific protocols
and evidence-based resources to ensure proper management. All of the information within
this PDF is believed to be accurate at the time of authorship, however there are no
guarantees that there are not any mistakes. Reputable sources were used in the creation of
this document, although they are not guaranteed to be updated. Please see my disclosure on
my website for more information.